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/` 3 APPLICATION FOR 5A ON PERMIT Permit No. <br /> �- - <br /> (Complete in Duplicate) Date Issued <br /> Application is hereby made to the San Joaquin Local.Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JO8 ADDRESS AND LOCATION-------------- -- --- -e---- - - <br /> -� I ---------------•-------------- <br /> Owner's Name--------------------------------------------- �" . ----•-----------r �.� ------------------- Phone------------------------------------ <br /> Address ---•---------------- f1; Gs <br /> Contractor's Name----------------------------------- -t- a_ R12 ¢----��-- Phone er E] <br /> Installation will serve: Residence.K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: __.�___ Number of bedrooms _ L Number of baths _/--- Lot size -__-�_ ------------------ <br /> Water Supply: Public system g Community system [1 Private ❑ Depth to Water Table 7­Z_ ft-N.-' - <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobejW Hardpan ❑ <br /> Previous Application Made: Yes ❑ N6A New Construction: Yes No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet. <br /> --=---- <br /> Septic Tank: Distance from nearest well_A Distance from fog"dation_______ _________-Material_-_:____-__-__--_-_______-.--___________ <br /> No. of compartments______---- Size_ �� �} ___Liquid depth__ _7-"-______-Capacity____ ov 5"------ <br /> Disposal <br /> ,-'_�--- <br /> ____Distance to nearest lot line____ _~.__ <br /> Disposal Field: Distance from nearest well---f`10'�_Distance from foundation---��__ __ oo `` <br /> Number of lines-------------- l_ength of each line-------�3_�'_--_______.Width of french-_--___7-41�__-_-______-____ N <br /> Type of filter material_____ 1_`_f �-Depth of filter material-----I Z_--_____._.Total length_____ f <br /> � ~• <br /> Seepage Pit: Distance to nearest well--- t -'.__-__171istanc from foundation___ Q__._______.D�snce to nearest tote_________________ <br /> Number of pits------I---------------Lining material----.--- ----'--- <br /> ---.Si..: Diameter--- ---------------.Depth---� <br /> Cesspool: Distance from nearest well------------------D(stance from foundation-.------------------Lining material-------------------------------------. <br /> Size: Diameter Depth _ _ _. Liquid Capacity =..gals::.. <br /> ❑ . ..'I- <br /> - `TDistance from nearest buildin <br /> Priv `f Distance from nearest well" --------------------------------- <br /> Y. ---- :_ 9 <br /> 0 Distance to nearest lot line--------------------------------------------------------------•-----------••--------•------------------------------------------------------- <br /> i <br /> Remodelingand/or repairing (describe):------------------------------------------ ----------------------------------------•-•--•-------------....---------._._...-------------------•---..... <br /> •- •-----------------------------•---------------------.-.-------------------•----------------------------••---------------------------------------------------•-------------------•------- <br /> ------------------- ----------- -•-------------------------------------------------------------------------------------------------------------------------------• -------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San .Joaquin County <br /> ordinances, State laws, and,rules and regulations of the San Joaquin Local Health District. <br /> �_-!T_l__'._1 ______ n wr Contractor <br /> (Signed) ` cam+ `' ------------------------ 4,4,4�{ ) <br /> By: -------- G-44-------------------------------------------------------------------------------(Title)---- 'a,"If, <br /> plan, sl3!o g size of lot, locatidn of system in relation to wells, buildings, <br /> can .be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY------------------- ------------------ ------------------------------ DATE--------------- ------------ <br /> REVIEWEDBY----=------------------------------- ------------------------------- -------------------------- ------------------ DATE----------------------------------------------•------- <br /> BUILDINGPERMIT ISSUED------------------------------------------ ---------------- -------I---------------------------------- DATE-------------------------------- ------------------------- <br /> Alterations and/or recommendations:---------------- ------------------------ ---------------------------------------------------------------------------------------- ------ <br /> ------------ <br /> ------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------- <br /> f <br /> ------------------- <br /> ---------------------------------------------------------------- ---------------------- ------ <br /> -- ----------- ----------------------------- ----------------------------- <br /> 7— <br /> FINAL <br /> ---- <br /> .—FINAL INSPECTION BY:-- offf Date-------------- - - - ---------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M 8-51 Revised W-2100 <br />